Impulse oscillometry (IOS) - validated technique measuring respiratory impedance that is used as an indicator of lung function. It requires minimal cooperation and is useful in preschool children (who often cannot perform acceptable spirometry), older children and adults
Exhaled nitric oxide (FeNO) - FDA: NIOX MINO cannot be used with infants or by children approximately under the age of 7, as measurement requires patient cooperation
Adjunct tests
Chest X-ray - usually indicated in the initial evaluation of a child with asthma, particularly if none have been performed previously
Peribronchiolar inflammatory changes and atelectasis are commonly observed in children with persistent asthma
Cotinine level - cotinine (nicotine metabolite with ~20 hour half-life) serum or urine level may document second-hand smoke exposure
Risk Factors for Developing Asthma
Asthma Predictive Indices
To have a positive API, a child must wheeze before age 3 years and have either 1 of 2 major criteria or 2 of 3 minor criteria.
Note
Children who wheezed frequently before age 3 years and had a positive API at age 3 years were nearly 10 times more likely to have active asthma at age 6 years and nearly 6 times more likely to have active asthma at age 13 years than children with a negative API
Modified API (mAPI) used for enrollment of children in PEAK study
Wheezing Phenotypes and Natural History
Treatment
Management of Early Childhood Asthma (Bacharier)
Treatment strategies for severe intermittent or mild persistent asthma
Daily treatment
Daily ICS is most effective in preventing exacerbations (but more likely to elicit ICS-related adverse effects)
Daily montelukast
6 months-5 years - 4 mg oral granules packet PO QD
2-5 years - 4 mg chewable tablet PO QD
6-14 years - 5 mg chewable tablet PO QD
≥15 years - 10 mg tablet PO QD
Daily low dose ICS
PEAK study: Fluticasone MDI 44 μg - 2 puffs BID via spacer/mask for 2-3 year olds with positive mAPI
CAMP study: Budesonide DPI 200 μg - 1 puff BID for 5-12 year olds with mild/moderate asthma
TREXA study: Beclomethasone HFA MDI 40 μg - 1 puff BID for 5-18 year olds with mild persistent asthma
MIST study: Budesonide 0.5 mg nebulized QHS for 1-4 year olds with positive mAPI
Intermittent treatment
May be considered for children with predominantly viral-induced exacerbations who are otherwise asymptomatic when healthy (low impairment)
MIST study: intermittent treatment equivalent to daily treatment with less adverse effects
Consider as a step down from daily ICS treatment
Intermittent montelukast - limited data on effectiveness
Intermittent high dose ICS
TREXA study: Beclomethasone HFA MDI 40 μg - 2 puffs of ICS with each 2 puffs of albuterol needed for symptoms
MIST study: Budesonide 1 mg nebulized BID x 7 days during respiratory tract illness
Advair only FDA approved for ages ≥4 years old for moderate/severe asthma, but NAEPP guideline approved for 0-4 year olds
Frequent follow-up to monitor control, compliance, inhaler technique, medication step-up or step-down
Monitor height - affects prepubertal children on ICS; in CAMP follow-up study mean adult height was 1.2 cm lower (95% CI 0.5-1.9 cm lower) in the budesonide group
NAEPP 2007 Guidelines
0-4 years old
5-11 years old
Note:
Weinberger: for viral-induced acute exacerbations of asthma in pre-school children, use oral steroids 30 mg/m2 of BSA PO BID; given early in the course of an exacerbation, adequate doses of oral corticosteroids are likely to decrease the high prevalence of urgent care and hospitalization
Differential Diagnosis
Table of Contents
Infections
Congenital problems
Mechanical/Airway problems
Other
Clues in History
Atypical wheezing
Physical Exam
Testing
Risk Factors for Developing Asthma
Asthma Predictive Indices
Note
Wheezing Phenotypes and Natural History
Treatment
Management of Early Childhood Asthma (Bacharier)
NAEPP 2007 Guidelines
0-4 years old
5-11 years old
Note:
References
Patient Hand-outs and Resources